Basic Information
| Provider Information | |||||||||
| NPI: | 1811510282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDSTEIN | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 20900 BISCAYNE BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056822483 | ||||||||
| FaxNumber: | 3056825250 | ||||||||
| Practice Location | |||||||||
| Address1: | 20900 BISCAYNE BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056822483 | ||||||||
| FaxNumber: | 3056825250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2020 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/18/2022 | ||||||||
| NPIReactivationDate: | 02/10/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.